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An Update from Medicare: A Complete Guide of the CMS Proposed Rule for 2020

Heads up! Here’s a recent update from Medicare. The Proposed Rule or the “Medicare Program; CY 2020 Revisions to Payment Policies under the Physician Fee Schedule and Other Changes to Part B Payment Policies” has finally been published. Since it contains 1704 pages, it’s not an easy read. Here is a brief break down of the most important details.  This will be your guide to re-read, analyze and understand every page of the proposed rules. Here are some of the important details and summary:

  • The proposed rule didn’t bring a lot of light to the unexpected changes to MIPS. In typical CMS fashion, they are slowly tightening the screws to make successful participation a little more difficult in 2019 than it was in 2018.
  • The proposed requirements for application of the new modifiers for services performed “in whole or in part” by PT or OT assistants are, (how can I say this delicately) crazy! If your organization has assistants, you should work on your plan to comply with these requirements right away. Documentation is key!
  • Our old friend, the “KX modifier threshold” formerly known as the Therapy Cap is unchanged. The exact amount of the cap (sorry, “threshold”, difficult to tell the difference) is yet to be determined by the Medicare Economic Index.
  • The targeted medical review threshold will be increased from $3,000 back to $3,700 as it was in prior years.



As stated above, no unexpected changes have been made including the low volume threshold, MIPS eligibility, data collection, or measure scoring. However, we highlighted some of the more important changes:

Minimum Performance Score

The minimum performance score for 2020 is expected to be increased from 30 to 45 points. This means a score of 45 in 2020 would be the minimum requirement to avoid a negative adjustment to your Medicare fee schedule in 2022.

Performance Category Weights

It is clear that CMS is working to increase the weighting of the Cost Category and decreasing the weighting of the Quality Category over time. For physicians, the Cost Category is scheduled to be increased from 15% of the weighting in 2019 to 20% in 2020, 25% in 2021, and 30% in 2022. It is not clear whether CMS has any plans to include the Cost Category as part of the performance weighting for PT and OT. However, it is uncertain if CMS has any plans to include the Interoperability Category as part of the PT and OT performance weighting.

Data Completeness

On QCDR measures, the proposal for minimum data completeness requirement is an increase from 60% to 70% of all eligible patients.

Preference for Outcomes Measures

CMS is continuing to emphasize that there is a preference for Outcomes Measures over Performance Based Measures. Those of you who remember the old PQRS program know that it was largely comprised of performance measures, like Fall Risk, Falls Plan of Care, BMI, etc. Expanding the Scope of QCDRs Currently, QCDRs are not required to support multiple performance categories. Beginning in 2021, QCDRs and Qualified Registries will be required to support multiple performance categories and QCDRs will have additional requirements to “foster improvement in the quality of care”. There is a lot more to understand about MIPS changes, but it is evident that MIPS is a program that is here to stay and successful participation in MIPS will be critical for Medicare providers.

“Harmonizing” Measures

QCDRs will be expected to eliminate duplication of measures. If similar measures exist in another QCDR, CMS may require that the measures are “harmonized” to eliminate duplicative measures.

Assistant Modifiers

New Assistant Modifiers will be required in 2020, and they would be an adjustment to the Medicare fee schedule for services performed “in whole or in part” by assistants beginning in 2022. However, it is still uncertain how CMS was planning to define what constituted services performed “in whole or in part” by assistants. Let’s say for example, when a PTA or OTA performs all of a service (as defined by a CPT code) in a given visit, all services performed by the PTA would require a CQ modifier in addition to the GP profession type modifier indicating physical therapy services. In right physical therapy billing company – services performed by an OTA would require a CO modifier in addition to the GO profession type modifier indicating occupational therapy services. It gets complex when talking about services performed partly by an assistant and partly by their supervising therapist during the same visit. In that scenario, the CQ or CO modifier is to be applied for those services (or CPT codes) when the time that the assistant is greater than 10% of the total time spent providing the service. Additionally, CMS is proposing two different methods for determining this 10% standard:

  • Method 1: Divide the total minutes of assistant provided service by the total minutes spent providing the service and round to the nearest whole number. If the number is 11%, then the assistant modifier is required for the service.


  • Method 2: Divide the total time spent providing the service by 10, round to the nearest whole number, and add 1 minute to identify the number of minutes of service that are required to exceed the 10% standard, then apply the modifier as appropriate.

If this sounds confusing to you, you are not alone! Check back here for more simplified explanations of these upcoming policy changes. Check out more often to read more latest news and updates. For medical billing needs, feel free to contact our medical billing company, or email us at info@ParkMedicalBilling.com.

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